Current RMA Instruments:

Changes from previous Instruments:

SOP Bulletin 190

 ICD Coding:

• ICD-9-CM Codes: 574
• ICD-10-AM Codes: K80

Brief descritpion

The gallbladder is a small, pear-shaped organ on the right side of the abdomen, beneath the liver. The gallbladder stores bile (a digestive fluid) for release into the small intestine.  Gallstones are stones formed within the galbladder from bile components.  They may remain in the gallbladder, where they can cause inflammation (cholecystitis) or enter the biliary tract, where they can cause obstruction (biliary colic).

Confirming the diagnosis

The diagnosis may be suspected on clinical grounds but needs to be confirmed by imaging (ultrasound, CT scan, MRI) or via endoscopic retrograde cholangiopancreatography (ERCP).

The relevant medical specialist is a gastroenterologist or a hepatobiliary/general surgeon.

Additional diagnoses covered by SOP

• choledocholithiasis
• gallstones
• gallstones in bile ducts
• gallstones with cholecystitis

Conditions excluded from SOP

• Biliary colic from other causes^#
• Cholecystitis in the absence of gallstones^#

^# non-SOP condition

Clinical onset

The condition may be asymptomatic and be found incidentally, or it may cause symptoms, typically of cholecystitis or biliary colic.  Clinical onset will be at the time of diagnosis (by imaging) for asymptomatic stones or may be backdated to the onset of characteristic symptoms once diagnosis has been confirmed.

Clinical worsening

Most patients who are asymptomatic will remain so. In patients who develop symptoms, a significant number will subsequently develop complications, including acute cholecystitis, choledocholithiasis (stone in common bile duct) with or without acute cholangitis, and gallstone pancreatitis.  Worsening beyond the normal course of the disease will be difficult to establish and will require specialist opinion.  Appropriate treatment depends on the clinical presentation and may range from observation through to surgery.